Healthcare Provider Details

I. General information

NPI: 1063627537
Provider Name (Legal Business Name): TIBBS CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/10/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301A HOSPITAL DR
CLEVELAND MS
38732-2358
US

IV. Provider business mailing address

ONE HOSPITAL DR
CLEVELAND MS
38732
US

V. Phone/Fax

Practice location:
  • Phone: 662-843-8314
  • Fax: 662-843-2644
Mailing address:
  • Phone: 662-843-8314
  • Fax: 662-843-2644

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number13568
License Number StateMS

VIII. Authorized Official

Name: DR. ROBERT CLINTON TIBBS III
Title or Position: OWNER
Credential: M.D.
Phone: 662-843-8314